General Surgery Flashcards
What presentations of ‘the acute abdomen’ require urgent intervention?
Acute bleeding
- ruptured AAA
- ruptured ectopic pregnancy, bleeding peptic ulcer or traumatic injury
Perforated viscus
-localised perforation can often present with localised pain and peritonism, tachycardia, and pyrexia (however may not necessarily look unwell!)
- generalised peritonitis will often present with tachycardia (+/- hypotension), pyrexia, and a rigid abdomen (and will look unwell!)
- urgent resus and cross-sectional imaging required
Ischaemic bowel
- severe pain out of proportion with clinical signs
- raised lactate and acidosis
- CT with IV contrast for definitive dx
How does peritonism (localised inflammation of the peritoneum) present?
patients will often report their pain starts in one place (irritation of the visceral peritoneum) before localising to one area (irritation of the parietal peritoneum) or becoming generalised.
What intial investigations are required for the ‘acute abdomen’?
Routine bloods– FBC, U&Es, LFTs, CRP, amylase, and a G&S (crossmatch if blood products or urgent surgery required)
Urine dipstick – for signs of infection or haematuria
- pregnancy test is performed for all women of reproductive age
ABG– useful in bleeding or acutely unwell patients for assessment of tissue hypoperfusion and rapid haemoglobin level
ECG– to assess for potential referred myocardial pain and for pre-op work-up if any surgery required
What imaging is required for the ‘acute abdomen’?
An erect CXR – for evidence of free abdominal air or lower lobe lung pathology
USS- most useful in assessing the renal tract (for hydronephrosis and cortico-medullary differentiation), biliary tree and liver (for gallstones, gallbladder thickening, or duct dilatation), and the uterus and adenexa (particularly if a transvaginal scan)
CT abdo pelvis - most useful in assessing for pathology in the GI tract e.g. bowel perf
Define haematemesis
vomiting fresh blood
Due to bleeding in Upper GI tract
Causes of haematemesis?
Oesophageal varices
Oesophagitis
Peptic ulcer disease
Mallory Weiss Tear
What should you ask in a hx of haematemesis?
Features of haematemesis – timing, frequency, and the volume of bleeding
Associated symptoms – including dyspepsia, dysphagia, melena, or weight loss
Past medical history – including the smoking & alcohol status
Drug history – use of steroids, NSAIDs, anticoagulants, or bisphosphonates
What should you assess for in examination of haematemesis?
epigastric tenderness or peritonism, hepatomegaly, and for any stigmata of liver disease
All patients with haematemesis must undergo what?
A gastroscopy - OGD
urgency determined by Glasgow-Blatchford score
If OGD is normal but ongoing bleeding suspected - CT angiogram
Immediate management of haematemesis due to peptic ulcer disease?
injections of adrenaline and cauterisation of the bleeding during endoscopy
How can causes of dysphagia be categorised?
mechanical obstruction (e.g. oesophageal cancer) or motility disorders (e.g. achalasia)
List some mechanical causes of dysphagia
Oesophageal cancer, Gastric cancer, or Head & Neck cancer
Benign oesophageal strictures
Oesophageal web (e.g. Plummer-Vinson syndrome)
Extrinsic compression (e.g. thyroid goitre)
Pharyngeal pouch
Foreign body (mainly in children)
List some motility related causes of dysphagia
Cerebrovascular accident
Achalasia
Diffuse oesophageal spasm
Myasthenia gravis
Muscular dystrophy
What should you ask in a hx of dysphagia?
exact nature of the symptom, including duration and frequency
clarify further:
Is there difficulty in initiating the swallowing action?
Do you cough after swallowing?
Do you have to swallow a few times to get the food to pass your throat?
Is it inability to swallow or pain on swallowing (odynophagia)?
Associated sxs: reflux or dyspepsia, hoarse voice, or referred pain (to neck or ear)
What should you examine in a patient presenting with dysphagia?
overt motor dysfunction, resting tremor, or dysarthria- point towards neuromuscular cause
examine the mouth for any obvious oral disease and examine the neck for any lymphadenopathy
Examine the abdomen for palpable masses
What is a Gastric Outlet Obstruction (GOO)?
a mechanical obstruction of the proximal GI tract, occurring at some level between the gastric pylorus and the proximal duodenum, resulting in an inability in the stomach to empty
What can cause a GOO?
peptic ulcer disease ( stricturing of the stomach/duodenum)
gastric cancer or small bowel cancer
iatrogenic
pancreatic pseudocyst
Bouveret Syndrome
gastric bezoar
Main differential for GOO?
gastroparesis, where patients have delayed gastric emptying - caused by neuromuscular dysfunction not mechanical obstruction, endoscopy / CT can differentiate
How might GOO present?
epigastric pain, postprandial vomiting, and early satiety
often no change in bowel habit initially due to proximal location of obstruction
OE:
tachycardic +/- hypotensive +/- oliguric (due to hypovolaemia)
tender and distended upper abdomen
localised peritonism or guarding may be present
“succession splash” on auscultation during sudden movement
How should GOO be investigated?
routine bloods:
FBC and CRP (to assess inflammatory markers)
U&Es (to assess for AKI, in the context of dehydration and hypovolaemia)
clotting screen and Group and Save (for work-up for surgery)
Abdo XR may show a gastric fluid level, however most cases will warrant a CT scan with IV contrast
Depending on the suspected underlying cause, a upper GI endoscopy can be performed (following stomach decompression)
- used to confirm the diagnosis (e.g. biopsy) and for therapeutic purposes
What is Bouvret syndrome?
GOO secondary to a gallstone impacted at the pylorus or proximal duodenum
occurs in patients with a cholecystoduodenal fistula, usually due to recurrent cholecystitis
attempt endoscopic removal then try enterotomy
How should GOO be managed?
resuscitation with IV fluids and catheterisation
NG tube to decompress the stomach (most important step)
IV PPI
In certain cases:
endoscopy to dilate benign stricturing (either balloon dilatation or stenting) or remove any luminal obstruction (bezoars, gallstones)
In most cases the mainstay of mx is surgical:
primary resection or gastrojejunostomy to bypass obstruction depending on underlying issue
What is a bowel obstruction?
mechanical blockage of the bowel, where a structural pathology physically blocks the passage of intestinal contents
Once the bowel segment has become occluded, gross dilatation of the proximal limb of the bowel occurs →
increased peristalsis of the bowel→secretion of large volumes of electrolyte-rich fluid into the bowel (‘third spacing’)
What can cause the bowel to be adynamic and not work properly without a mechanical obstruction?
Ileus
Pseudo-obstruction
What is a closed loop bowel obstruction?
In patients with a mechanical bowel obstruction where there is a second separate obstructing point proximally (e.g. a large bowel obstruction with a competent ileocaecal valve)
surgical emergency→if not corrected, the bowel will continue to distend within a closed segment, stretching the bowel wall until it becomes ischaemic→ may perforate!!
What are the most common causes of bowel obstruction?
depends on location
Small bowel – adhesions or hernia
Large bowel – malignancy, diverticular disease, or volvulus
Give 3 intraluminal causes of bowel obstruction
Gallstone ileus, ingested foreign body, faecal impaction
Give some mural causes of bowel obstruction
Cancer
inflammatory strictures (esp in Crohn’s)
diverticular strictures
intussusception (usually in kids)
Meckel’s diverticulum
lymphoma
Give 4 extramural causes of bowel obstruction
Hernias, adhesions, peritoneal metastasis, volvulus
How does bowel obstruction present?
Abdominal pain – colicky or cramping (secondary to the bowel peristalsis)
Vomiting – occurring early in proximal obstruction and late in distal obstruction
Abdominal distension
Absolute constipation – occurring early in distal obstruction and late in proximal obstruction
What can be found on examination of bowel obstruction?
evidence of the underlying cause (e.g. surgical scars, cachexia from malignancy, or obvious hernia)
abdominal distension
focal tenderness (including guarding and rebound tenderness on palpation- only present if ischaemia developing)
percussion = tympanic sound
auscultation = ‘tinkling’ bowel sounds
Why should you assess fluid status in bowel obstruction?
may have significant third spacing
Differentials for bowel obstruction?
pseudo-obstruction
paralytic ileus
toxic megacolon
constipation
Investigations for bowel obstruction?
urgent bloods including Group & Save
monitor renal function and U&Es (risk of 3rd spacing)
VBG for metabolic derangement
Imaging:
CT with IV contrast is the mainstay
AXR sometimes used
Signs of small bowel obstruction on AXR?
Dilated bowel (>3cm), central abdominal location, and valvulae conniventes visible (lines completely crossing the bowel)
Signs of large bowel obstruction on AXR?
Dilated bowel (>6cm, or >9cm if at the caecum), peripheral location, and haustral lines visible (lines not completely crossing the bowel, ‘indents that go Halfway are Haustra’)
What is the conservative management of bowel obstruction? What should you do if it does not appear to be resolving?
In the absence of ischaemia or perforation, initial management for adhesional bowel obstruction is conservative : ‘DRIP AND SUCK’
drip : start IV fluids and correct electrolyte disturbances (+ urinary catheter and fluid balance)
suck: make patient NBM and insert and NG tube to decompress bowel
adequate analgesia
If it doesn’t resolve with conservative management : water soluble contrast study (e.g Gastrograffin)
AXR after around 6hrs since oral contrast to see evidence of ongoing obstruction versus resolution
When is surgical intervention indicated for bowel obstruction? What are the options?
Indications:
Suspicion of intestinal ischaemia or closed loop bowel obstruction
A cause that requires surgical correction (such as a strangulated hernia or obstructing tumour)
If patients fail to improve with conservative measures (typically after ≥48 hours)
Mainstay = laparotomy
If bowel resection is required, the re-joining of obstructed bowel is often not possible and a defunctioning stoma may be necessary
What are the complications of bowel obstruction?
bowel ischaemia or bowel perforation leading to faecal peritonitis (high mortality)
AKI and end organ injury due to fluid depletion
Why should GI perforation be one of the first diagnoses considered in all patients who present with acute abdominal pain?
Delay in resuscitation and definitive surgery of any perforation will progress rapidly into septic shock, multi organ dysfunction, and death
Causes of Upper GI perforation?
Peptic ulcer disease
Gastric cancer or oesophageal cancer
Foreign body ingestion (e.g. battery or caustic soda)
Excessive vomiting (Boerhaave Syndrome)
Causes of lower GI perforation?
Diverticulitis
Colorectal cancer
Appendicitis or Meckel’s Diverticulitis
Foreign body insertion
Severe colitis, such as Crohn’s Disease
Toxic megacolon (e.g. from C .Diff or UC)
What can cause GI perforation anywhere along the tract?
TIMO
Trauma
Iatrogenic, such as during gastroscopy or colonoscopy
Mesenteric ischaemia
Obstructing lesions (e.g. cancer, bezoar, or faeces)
Investigations for suspected GI perforation?
same bloods as for any patient with an acute abdomen : FBC, U&Es, LFTs, CRP, clotting, and G&S
will have raised WCC and CRP
maybe signs of end organ damage e.g. AKI or coagulopathy due to sepsis
Imaging:
CT with IV contrast is gold standard (or oral contrast in suspected Upper GI)
What would you see on X-ray in a GI perf?
CXR: air under the diaphragm in cases of pneumoperitoneum
AXR: Rigler’s sign (both sides of the bowel visible), or psoas sign (loss of the sharp delineation of the psoas muscle border)
Management of suspected GI perf?
General:
early broad spectrum abx
NBM and NG tube insertion
IV fluid resuscitation and analgesia
management then depends on underlying cause - perforated viscus usually goes to theatre for repair and contamination control
The key aspects of any surgical intervention for a GI perforation are:
Identification of the underlying cause
Appropriate management of perforation
Thorough washout
How is a peptic ulcer perf managed surgically?
accessed typically either open or laparoscopically and a patch of omentum (termed a “Graham patch”) is tacked loosely over the ulcer
How is a small bowel perf managed surgically?
bowel resection +/- primary anastomosis +/- stoma formation
on occasion, small perforations (e.g. a fish bone perforation) can be managed by oversewing the defect
How is a large bowel perf managed surgically?
high risk of contamination
bowel resection +/- stoma formation
Who is suitable for conservative management of a GI perf?
Localised diverticular perforation with only localised peritonitis and tenderness, and no evidence of generalised contamination
Patients with a sealed upper GI perforation on CT imaging without generalised peritonism
Elderly frail patients with extensive co-morbidities who would be very unlikely to survive surgery
What is melaena?
black tarry offensive smelling stool usually caused by Upper GI bleeding
often difficult to flush
caused by alteration of digested blood by intestinal enzymes
The key facts to ascertain from a patient presenting with melena are:
Colour and texture of the stool – best described as a jet black, tar-like, and sticky
Associated symptoms – including any haematemesis, abdominal pain, weight loss, dyspepsia, or dysphagia
Past medical history – including smoking and alcohol status
Drug history – use of steroids, NSAIDs, anticoagulants, or iron tablets
Examinations for patients presenting with melaena?
Abdo exam and DRE
All patients with new onset melaena must undergo what?
An OGD - urgency determined by Glasgow-Blatchford score
If OGD inconclusive:
CT angiogram - assessing for any active bleeding, especially in those with suspected ongoing bleeding or haemodynamic compromise
Colonoscopy - especially if haemodynamically stable, to ensure that the cause of the melena is not actually proximal colonic in origin (e.g. a caecal tumour)
What causes appendicitis?
direct luminal obstruction
usually secondary to a faecolith
can also be due to lymphoid hyperplasia, impacted stool or (rarely) an appendiceal or caecal tumour
when obstructed commensal bacteria multiply and cause inflammation
Risk factors for appendicitis?
most common in patients between 20-30yrs
Family history
- twin studies suggest that genetics = 30% of risk
Ethnicity
- more common in Caucasians
Environmental
-seasonal presentation during the summer
Clinical features of appendicitis?
abdo pain
- initially peri-umbilical, classically dull and poorly localised (from visceral peritoneum inflammation)
- later migrates to RIF, where it is well-localised and sharp (from parietal peritoneum inflammation)
anorexia and N+V
OE: rebound tenderness and percussion pain over McBurney’s point (2/3 of the way between umbilicus and ASIS)
What 2 specific signs can be found O.E of appendicitis?
Rovsing’s sign: RIF fossa pain on palpation of the LIF
Psoas sign: RIF pain with extension of the right hip
Specifically suggests an inflamed appendix abutting psoas major muscle in a retrocaecal position
How can appendicitis present in children?
What should you be sure to examine?
a high proportion of acute appendicitis in children will present atypically - diarrhoea, urinary symptoms, or even left sided pain
examine cardioresp and urinary systems as well as GI
genital examination in all boys, to exclude testicular torsion or epididymitis
Remember, a child under 6 years of age who has had symptoms of acute appendicitis for over 48 hours is much more likely to have what?
A perforation!!!
Requires active observation
Differentials for appendicitis?
Gynaecological: ovarian cyst rupture, ectopic pregnancy, PID
Urological: testicular torsion, epididymo-orchitis
Renal: ureteric stones, UTI, pyelonephritis
Gastrointestinal: inflammatory bowel disease, Meckel’s diverticulum, or diverticular disease
What are the best risk stratification systems for appendicitis in men women and children?
Men – Appendicitis Inflammatory Response Score
Women – Adult Appendicitis Score
Children – Shera score
What is the management for appendicitis with an appendiceal mass?
antibiotic therapy is favoured, with an interval appendectomy performed approximately 6-8 weeks later
What is the gold standard surgical intervention for appendicitis?
Laparascopic appendectomy- low morbidity and allows better visualisation of ovaries and uterus
appendix should routinely be sent to histopathology to look for malignancy
abdomen should be inspected for other pathology including Meckel’s diverticulum
Complications of acute appendicitis?
Perforation - if left untreated the appendix can perforate and cause peritoneal contamination
(esp in children who may have a delayed presentation)
Surgical site infection
Appendix mass - omentum and small bowel adhere to the appendix
Pelvic abscess
- presents as fever with a palpable RIF mass, can be confirmed w CT scan ; management is usually with abx and percutaneous drainage of abscess
What is Pseudo-obstruction? (also known as Ogilvie syndrome)
Where does it most commonly affect?
dilatation of the colon due to an adynamic bowel, in the absence of mechanical obstruction
most commonly affects the caecum and ascending colon
thought to be due to an interruption of the autonomic nervous supply to the colon
What can cause pseudo-obstruction?
- it MEaNT to look like an obstruction :)
Medication
- opioids, CCBs, or anti-depressants
Electrolyte imbalance or endocrine disorders
- hypercalcaemia, hypothyroidism, or hypomagnesaemia
Neurological disease
- Parkinson’s disease, Multiple Sclerosis, and Hirschsprung’s disease
Trauma - recent surgery, severe illness, or trauma
- incl. cardiac ischaemia
Clinical features of pseudo-obstruction?
same as for mechanical obstruction
- Abdominal pain and distension
- Constipation
- whilst not passing ‘normal’ stool, often patients
may have paradoxical diarrhoea
- whilst not passing ‘normal’ stool, often patients
- Vomiting
- late feature due to the colon being most distal in
the GI tract
- late feature due to the colon being most distal in
On examination, the abdomen will be distended and tympanic
Investigations for pseudo-obstruction?
blood tests - assess for biochemical or endocrine causes of pseudo-obstruction, including U&Es, Ca2+, Mg2+, and TFTs
CT abdo-pelvis with IV contrast - rule out mechanical cause
Motility studies will often be required in the long-term
How should cases of pseudo-obstruction that do not resolve within 24-48 hours be managed?
endoscopic decompression = mainstay of treatment (insertion of flatus tube)
if limited resolution, use of IV neostigmine (an anticholinesterase) may be trialled
Outline the 2 types of inguinal hernia and the patient groups they occur in
Direct inguinal hernia (20%)
- Bowel enters the inguinal canal directly through a weakness in the posterior wall (Hesselbach’s triangle)
- medial to inferior epigastrics
- older patients, often secondary to abdominal wall laxity or a significant increase in intra-abdominal pressure
Indirect inguinal hernia (80%)
- Bowel enters the inguinal canal via the deep inguinal ring
- lateral to inferior epigastrics
- due to incomplete closure of the processus vaginalis, congenital in origin
Risk factors for inguinal hernia?
Male gender
Increasing age
Raised intra-abdominal pressure, from chronic cough, heavy lifting, or chronic constipation
High BMI
What specific features should be noted on examination for inguinal hernia?
Location – inguinal hernias appear superomedial to the pubic tubercle (whilst femoral hernias appear inferolateral to the pubic tubercle)
Cough impulse – an irreducible hernia may not have a cough impulse
Reducible – On lying down or with gentle pressure
If it enters the scrotum, can you get above it / is it separate from the testis
How can you differentiate between the 2 types of inguinal hernia?
reduce the hernia and then place pressure over the deep inguinal ring (located at the mid-point of the inguinal ligament), before asking the patient to cough
If the hernia protrudes despite occlusion of the deep inguinal ring, this indicates a direct hernia
This is often unreliable and surgical exploration is more definitive
Differentials for an inguinal hernia?
Groin lump: femoral hernia, saphena varix, inguinal lymphadenopathy, lipoma, or groin abscess
How should an inguinal hernia be investigated?
clinical diagnosis, imaging only required if diagnostic uncertainty
USS first line
CT imaging if features of obstruction or strangulation
What are the options for hernia repair?
open repair (Lichtenstein technique) or laparoscopic repair (either total extraperitoneal (TEP) or transabdominal pre-peritoneal (TAPP))
open mesh repairs are preferred for those with primary inguinal hernias
laparoscopic approach is preferred in those with bilateral or recurrent inguinal hernias
can also be considered in patients with a primary unilateral hernia if:
1. at a high risk of chronic pain (young and active, previous chronic pain,predominant symptom of pain)
2. female (due to the increased risk of the presence of a femoral hernia)
The serious complications of a hernia that require urgent intervention are:
Irreducible / incarcerated – the contents of the hernia are unable to return to their original cavity
Obstruction – the bowel lumen has become obstructed, leading to the clinical features of bowel obstruction
Strangulation – compression of the hernia has compromised the blood supply, leading to the bowel becoming ischaemic
Complications of inguinal hernias? complications of surgical repair?
incarceration, strangulation, and obstruction
complications following elective hernia repair:
haematoma or seroma formation
recurrence
chronic pain
damage to vas deferens or testicular vessels
Femoral herniae are relatively uncommon. Why are they an important problem?
High risk of strangulation due to narrow neck
Risk factors for developing a femoral hernia?
Female (3:1 F:M)
Pregnancy (higher incidence in multiparous women)
Raised intra-abdominal pressure (e.g. heavy lifting, chronic constipation)
Increasing age
What is Athletic Pubalgia?
impingement of abdominal wall musculature due to small tear in rectus sheath, common in young athletes
All femoral hernias should be managed surgically, ideally within 2 weeks of presentation, due to the high risk of strangulation.
What are the 2 different surgical approaches?
Low approach – incision made below the inguinal ligament
+ doesn’t interfere with the inguinal structures
- limited space for the removal of any compromised small bowel
High approach – the incision is made above the inguinal ligament
+ is the preferred technique in an emergency intervention due to the easy access to compromised small bowel
Key features of an epigastric hernia?
herniates in upper midline through the fibres of the linea alba
asymptomatic or midline mass that disappears when lying on back
mostly in middle aged men
important differential diagnosis is divarication of the recti
Key features of a paraumbilical hernia?
through the linea alba around the umbilical region
usually secondary to raised intra-abdominal pressure, risk factors include obesity and pregnancy
generally contain pre-peritoneal fat, do not commonly strangulate
Key features of a spigelian hernia?
occurs around the level of the arcuate line
small tender mass at the lower lateral edge of the rectus abdominus
high risk of strangulation, urgent repair required
Key features of an obturator hernia?
hernia of the pelvic floor, occurring through the obturator foramen into the obturator canal
more common in women (due to a wider pelvis), typically in elderly patients
present with a mass in the upper medial thigh and often features of small bowel obstruction
50% have compression of the obturator nerve and
+ve Howship-Romberg sign
What are Richter’s herniae?
partial herniation of bowel involving the anti-mesenteric border
What are the basic principles of wound management?
Haemostasis
Cleaning the wound
Analgesia
Skin closure
Dressing and follow-up advice
What are the 5 aspects of wound cleaning?
- Disinfect the skin around the wound with antiseptic
(avoid getting alcohol or detergents inside the wound) - Decontaminate the wound by manually removing any foreign bodies
- Debride any devitalised tissue where possible
- Irrigate the wound with saline
- if no obvious contamination present, low pressure irrigation is sufficient (pouring normal saline from a sterile container carefully into the wound) - Antibiotics for high-risk wounds or signs of infection
Risk factors for wound infection?
foreign body present or heavily soiled wounds, bites (including human), puncture wounds, and open fractures
What is the maximum level of local anaesthetic given for wound closure?
maximum level of lidocaine is 3mg/kg and the addition of adrenaline allows for up to 7mg/kg
remember to not use adrenaline with local anaesthetic if administering in or near appendages (e.g. a finger)
4 main methods of manually opposing a wound?
- Skin adhesive strips (e.g. Steri-StripsTM) are suitable if no risk factors for infection are present
- Tissue adhesive glue (e.g. Indermil) - used for small lacerations with easily opposable edges (a popular choice in paeds)
- Sutures - used for any laceration greater than 5cm, deep dermal wounds, or in locations that are prone to flexion, tension, or wetting
- Staples can be used for some scalp wounds
How should you apply a wound dressing to a non-infected laceration?
the first layer should be non-adherent (such as a saline-soaked gauze), followed by an absorbent material to attract any wound exudate, and finally soft gauze tape to secure the dressing in place
When should sutures or adhesive strips be removed?
sutures or adhesive strips should be removed 10-14 days after initial would closure (or 3-5 days if on the head)
tissue adhesive glue will naturally slough off after 1-2 weeks
Why are malnourished patients poor surgical candidates?
Surgery causes physiological stress with a resultant hyper-metabolic state and catabolic response
Malnourished patients are at increased risk of post-operative complications, such as reduced wound healing, increased infection rates, and skin breakdown
Outline the simple hierarchy of feeding methods that should be used for surgical patients
If unable to eat sufficient calories - Oral nutritional Supplements (ONS)
If unable to take sufficient calories orally or dysfunctional swallow - Nasogastric tube feeding (NGT)
If oesophagus blocked/dysfunctional - Gastrostomy feeding (PEG/RIG)
If stomach inaccessible or outflow obstruction- Jejunal feeding (jejunostomy)
If jejunum inaccessible or intestinal failure (IF) - Parenteral nutrition
What is the stepwise approach to tx in patients with intestinal failure?
SNAP
Sepsis – Any overwhelming infection present must be corrected otherwise feeding will be largely useless
Nutrition – Once the infection is corrected, suitable nutritional support should be provided
Anatomy – Define the anatomy of the GI tract so that surgery can be planned
Procedure – Definitive surgery once any infection eradicated, the patient nourished, and the anatomy defined
What are the principles of Enhanced Recovery After Surgery (ERAS)?
Reduction in ‘Nil By Mouth’ times (clear fluids up to 2 hours pre-surgery)
Pre-operative carbohydrate loading
Minimally invasive surgery
Minimising the use of drains and nasogastric tubes
Rapid reintroduction of feeding post-operatively
Early mobilisation
When after uncomplicated GI surgery can a patient safely tolerate an enteral diet?
after 24 hrs
What are the options for nutritional management of Entero-cutaneous Fistulae (ECF)?
dependent upon the level of the fistula so imaging often required to decide how to manage effectively
High fistula (jejunal) may need support with enteral or parenteral nutrition
Low fistulae (ileum/colon) can be treated with low fibre diet
The nutritional support and treatment for High Output Stoma (HOS) is dependent upon the length of bowel to stoma.
Outline the nutritional requirements for different positions of jejunostomy
Distance From DJ Flexure to Jejunostomy :
150-200cm = Enteral support
100-150cm =Enteral support +/- IV fluids
<100cm = Parenteral Nutrition
Outline the nutritional requirements for different positions of colostomy
Distance From DJ Flexure to Colostomy:
100-150cm = Enteral support
50-100cm = Enteral support +/- IV fluids
<50cm = Parenteral Nutrition
Once active disease or infection has been excluded, then a reduction in stoma output can be achieved by:
- Reduction in hypotonic fluids to 500ml/day
- Reduction in gut motility with high dose loperamide and codeine phosphate
- Reduction in secretions with high dose PPI (a twice daily dose)
- Use of WHO solution to reduce sodium losses
- Low fibre diet to reduce intraluminal retention of water
What ECG pattern indicates severe hyperkalaemia?
A sinusoidal ECG pattern - (K > 9 mmol/L)
List some key causes of RIF pain
Appendicitis
Crohn’s
Mesenteric Adenitis
Diverticulitis
Meckel’s Diverticulitis
Incarcerated right inguinal or femoral hernia
Bowel perf
Gynae/uro causes
Causes of abdo swelling?
Pregnancy
Ascites -History of alcohol excess, cardiac failure
Intestinal obstruction- History of malignancy/previous operations, vomiting, ‘tinkling’ bowel sounds
Urinary retention - History of prostate problems
Dullness to percussion around suprapubic area
Ovarian cancer - Older female, Pelvic pain
Urinary symptoms e.g. urgency
Raised CA125
Early satiety, bloating
Factors that increase the risk of abdominal wound dehiscence?
Malnutrition
Vitamin deficiencies
Jaundice
Steroid use
Major wound contamination (e.g. faecal peritonitis)
Poor surgical technique (Mass closure technique is the preferred method-Jenkins Rule)
Mx of abdominal wound dehiscence?
Coverage of the wound with saline soaked gauze (on the ward)
IV broad-spectrum antibiotics and fluids
Analgesia
Arrangements made for a return to theatre
Key questions to ask for groin lumps?
Is there a cough impulse?
Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm)?
Are both testes intra scrotal?
Any lesions in the legs such as malignancy or infections (?lymph nodes)
Examine the ano rectum as anal cancer may metastasise to the groin
Is the lump soft, small and very superficial (?lipoma)
Key questions to ask for scrotal lumps?
Is the lump entirely intra scrotal?
Does it transilluminate (?hydrocele)
Is there a cough impulse (?hernia)
Indications for surgery in lower GI bleeding?
Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension
Key management steps of lower GI bleeding?
All patients should have a history and examination, PR and proctoscopy
Colonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding
Massive haemorrhage is the loss of one blood volume in a 24 hour period or the loss of 50% of the circulating blood volume in 3 hours.
Complications of tx for massive haemorrhage?
Hypothermia - Blood is refrigerated, shifts Bohr curve to the left
Hypocalcaemia - Both FFP and platelets contain citrate anticoagulant which may chelate calcium
Hyperkalaemia - Plasma of red cells stored for 4-5 weeks contains 5-10 mmol K+
Coagulopathy - Anticipate once circulating blood volume transfused
1 blood volume usually drops platelet count to 100 or less and dilutes and clotting factors
Delayed type transfusion reactions - Due to minor incompatibility issues especially if urgent or non cross matched blood used
Transfusion related lung injury - Acute onset non cardiogenic pulmonary oedema
- leading cause of transfusion related deaths
- occurs as a result of leucocyte antibodies in transfused plasma and aggregation and degranulation of leucocytes in lung tissue
What nerve lesions may result from:
Posterior triangle lymph node biopsy
Carotid endarterectomy
Thyroidectomy
Anterior resection of rectum
Axillary node clearance
Inguinal hernia surgery
Varicose vein surgery
Posterior approach to the hip
Posterior triangle lymph node biopsy = accessory nerve lesion
Carotid endarterectomy = hypoglossal nerve
Thyroidectomy = laryngeal nerve
Anterior resection of rectum = hypogastric autonomic nerves
Axillary node clearance = long thoracic nerve, thoracodorsal nerve and intercostobrachial nerve
Inguinal hernia surgery = ilioinguinal nerve
Varicose vein surgery = sural and saphenous nerves
Posterior approach to the hip = sciatic nerve
A pathological fracture occurs in abnormal bone due to insignificant injury. Give some underlying causes
Metastatic tumours:
Breast , Bronchus (Lung) , Bhyroid , Bidneys , Brostate
Primary malignant tumours
Chondrosarcoma , Osteosarcoma , Ewing’s tumour
Bone disease
Osteogenesis imperfecta, Osteoporosis, Paget’s disease
Local benign conditions
Chronic osteomyelitis, Solitary bone cyst
5 main causes of shock?
Septic
Haemorrhagic
Neurogenic
Cardiogenic
Anaphylactic
What is required to meet the diagnostic criteria for sepsis?
infections and two or more elements of SIRS (systemic inflammatory response syndrome)
body temperature outside 36 oC - 38 o C, HR >90 beats/min, respiratory rate >20/min, WBC count >12,000/mm3 or < 4,000/mm3
What causes neurogenic shock?
spinal cord transection, usually at a high level
decreased sympathetic tone or increased parasympathetic tone = decrease in peripheral vascular resistance and marked vasodilation
What is flail chest?
When the chest wall disconnects from thoracic cage
Multiple rib fractures (at least two fractures per rib in at least two ribs)
Associated with pulmonary contusion
Abnormal chest motion
Avoid over hydration and fluid overload
Cause of haemothorax? Mx?
Most commonly due to laceration of lung, intercostal vessel or internal mammary artery
Haemothoraces large enough to appear on CXR are treated with large bore chest drain
Surgical exploration (thoractomy) is warranted if >1500ml blood drained immediately or losses of >200ml per hour for >2 hours
How can blunt cardiac injury present?
Usually occurs secondary to chest wall injury
ECG may show features of myocardial infarction
Sequelae: hypotension, arrhythmias, cardiac wall motion abnormalities
Differentiate between the different types of graft:
Allograft - Transplant of tissue from genetically non identical donor from the same species (kidney from donor) - ‘allo there neighbour!
Isograft - Graft of tissue between two individuals who are genetically identical (kidney from twin)
Autograft - Transplantation of organs or tissues from one part of the body to another in the same individual (skin graft)
Xenograft - Tissue transplanted from another species (porcine heart valve)
Complications of enteral feeding?
diarrhoea - 1 in 6 patients
aspiration
metabolic
- hyperglycaemia, refeeding syndrome
Achalasia increases risk of which oesophageal cancer?
squamous cell carcinoma
A 68 year of man presents with recurrent episodes of left sided ureteric colic and haematuria. Investigations show some dilatation of the renal pelvis but the outline is irregular. Diagnosis?
Transitional cell carcinoma
These arise from urothelium and necessitate a nephroureterectomy
The Parkland formula for fluid resuscitation in burns is:
Volume of fluid = total body surface area of the burn % x weight (Kg) x 4ml
Irreducible, painful lump inferolateral to the pubic tubercle →
?strangulated femoral hernia
Pregnancy and frank haematuria, especially if there is a history of placenta previa or prior caesarean section, should indicate what diagnosis?
Placenta percreta
placental implantation into the myometrium
A 45-year-old woman presents with haematuria and loin pain. She has a normal temp and is found to have a Hb 180 g/l and a creatinine of 156 umol/l. Her urine dipstick shows 3+ blood. Blood and urine cultures are negative.
Dx?
Renal vein thrombosis - common feature of renal cell carcinoma as it invades the renal vein.
Looking for small and large bowel obstruction is one of the key indications for performing an abdominal film.
How should small bowel and large bowel appear?
Small bowel
Maximum normal diameter = 35 mm
Valvulae conniventes extend all the way across
Large bowel
Maximum normal diameter = 55 mm
Haustra extend about a third of the way across
What is Boas’ sign?
In acute cholecystitis there is hyperaesthesia beneath the right scapula.
It occurs because the abdominal wall innervation of this region is from the spinal roots that lie at this level
72-year-old woman with a history of congestive cardiac failure. She reports having a poor appetite and feeling bloated. She is admitted frequently to hospital with LV failure due to poor compliance with medication. Diagnosis?
ascites
poorly controlled HF can cause ‘cardiac cachexia’, partly due to gut oedema
How does angiodysplasia present?
arteriovenous lesions, right side of colon more commonly affected
Apart from bleeding, which may be massive, these cause few symptoms
A 17-year-old male is admitted with lower abdominal discomfort. He has been suffering from intermittent RIF pain for the past few months. His past medical history includes a negative colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal.
Dx?
Meckel’s diverticulum - small outpouching of small intestine
- may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration
What is Mitterlschmerz?
mid cycle (ovulation) pain
RIF or LIF
occurs because a small amount of fluid is released at the time of ovulation. It will usually resolve over 24-48 hours
A 16-year-old boy presents with severe groin pain after kicking a football. Imaging confirms a pelvic fracture. A previous pelvic x-ray performed 2 weeks ago shows a lytic lesion with ‘onion type’ periosteal reaction
Dx?
Ewings sarcoma
is most common in males between 10-20 years
A lytic lesion with a lamellated or onion type periosteal reaction is a classical finding on x-rays
Most patients present with metastatic disease
How should congenital inguinal hernias be managed?
Should be surgically repaired soon after diagnosis as at risk of incarceration
How do infantile umbilical hernias present?
Symmetrical bulge under the umbilicus
More common in premature and Afro-Caribbean babies
The vast majority resolve without intervention before the age of 4-5 years
Complications are rare
What can cause bowel obstruction of both the small and large bowel concurrently in the elderly?
incompetent ileocaecal valve
Characteristic sign of bowel cancer on X-ray?
apple core sign with barium swallow
A 22 year man is shot in the groin. On examination he has weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh.
What nerve has been damaged?
femoral nerve
